High burden to high impact: a targeted malaria response. Malaria Policy Advisory Committee (MPAC) October 2018, Geneva

Transcription

1 High burden to high impact: a targeted malaria response Malaria Policy Advisory Committee (MPAC) October 2018, Geneva

2 Malaria in numbers m 12b b 10+1

3 The problem Million cases Rising number of malaria cases

4 Initial focus: high burden African countries Additional cases between 2015 and Nigeria DR Congo India Niger Mali UR Tanzania Mozambique Burkina Faso Ghana Uganda Cameroon

5 An urgent and credible response Four key mutually reinforcing response elements Best global guidance Political commitment Strategic use of information Impact Coordinated response

6 More impact by improving value for money Economy Efficiency Effectiveness Resources Inputs Outputs Outcome Impact Cost effectiveness Equity

7 Theory of change Finances and political capital HRH and commodities Delivery of optimal mix of interventions Reduced malaria mortality Socioeconomic development Political Commitment Health governance and financing 1 2

8 Translating political will into domestic funding Nigeria Million US$ 0 50M 100M 150M 200M 250M 300M 350M 0 50,000, ,000, ,000, ,000, ,000, ,000, ,000,000 DR Congo DRC Mozambique Ghana Mali Burkina Faso Niger Uganda Tanzania Cameroon India Government Funding External Funding

9 Percentage Improving budget execution Achieving efficiency through better health governance Realized expenditure Unspent budget

10 Improving the health delivery system Country UHC SCI Physicians per 1000 population Hospital beds per population Burkina Faso 39 Less than Cameroon DR Congo Ghana Mali Mozambique Niger Nigeria Uganda Tanzania 39 Less than India Greece (for reference)

11 Improving efficiencies By truly aligning behind an evidence based approach

12 Theory of change Finances and political capital HRH and commodities Delivery of optimal mix of interventions Reduced malaria mortality Socioeconomic development Political Commitment Health governance and financing Market shaping Strategic use of local information

13 10+1 response elements 1 Galvanize national and global political attention to reduce malaria deaths 2 Drive impact in country through strategic use of information 3 4 Establish best global guidance, policies and strategies suitable for the broad range of contexts A coordinated country response

14 Billions (US$) Estimation of funding need and gap RBM funding gap analysis Funding gap Funding available NSP period DRC Ghana Nigeria Uganda Mozambique

15 Estimation of funding need and gap US$ per case averted based estimated need DRC Ghana Mozambique Nigeria Uganda Are the differences due to varying efficiencies or poor costing?

16 Percentage Percentage Equity data from a high burden country Access to ITNs: percentage of people with enough ITNs in their households Most poor Least poor None or primary education Secondary or higher education 2x more children under the age of five years die in poorest households compared to the wealthiest!!

17 Percentage Percentage Equity data from a high burden country Most poor None or primary education Least poor Secondary or higher education Treatment seeking for fevers in children under the age of five years 2x more children under the age of five years die in poorest households compared to the wealthiest!!

18 Percentage Efficiency data from a high burden country Access to ITNs: Percentage of people with enough ITNs in their households 20 0 Urban Rural 57 million 54% 44 million 29 million Population 2017 LLINs distributed Number of nets required for universal coverage in 2017 Population access to LLINs in 2017

19 Stratification metric and geography DRC Uganda Nigeria

20 Use of strategic information LLIN targeting in Kenya, 2010 A) A 3D population map showing areas where PfPR 2-10 was <1% (pink) and >1% (dark red) B) Map showing percentage ITN use from low C) Population that need LLINs in areas to be targeted based on a criteria of >1% PfPR 2-10 and >1 person per square km (green) and those additional who will need LLIN if the whole country was targeted (pink) From 16 to 6 million nets, or US$ 55 million difference in costs of LLLINs at the time

21 Use of strategic information Tanzania, 2008 NSP LLINs everywhere! MARA climate suitability map

22 Use of strategic information Tanzania, 2018 Reduction in prevalence until 2019, CM and LARV not enough to reduce prevalence but enough to maintain low prevalence until In practice ITN distribution might need to be considered in specific areas. Reduction in prevalence until 2019, CM and LSM not enough to reduce prevalence and ITN continuous needs to be considered Prevalence % trend by stratum Annual ITNs maintaining coverage of 70% with increase in CM to 85% reduces the prevalence in moderate strata by xx% High reduction in prevalence in high strata with CM, ITNs, IRS (LAKE) IPTsc might add additional impact With CM and LARV only prevalence is increasing in this stratum ITN distribution need to follow epidemiological strata to achieve decrease in all urban districts

23 What is new in the analysis approach? Current National Strategic Plan Monitoring and Evaluation Country status review NSP development, adoption and action Re-stratification (usually province and occasionally district) (e.g. MIS, (e.g. MTR, Update vision, mission, objectives and goals programme MPR, impact (Vision, Building the right data platforms and Strategic databases intervention approaches mission, goals, data, routine evaluations objectives, HIS data etc.) etc.) Performance framework interventions, Better stratification with improved spatial Action plan resolution action plan, cost, funds) Resource mobilization (funding need and gap) Optimized intervention mixes guided Implementation by a robust analysis of anticipated impact Low data Low quality reviews No clear approach to stratification and intervention coverage (space mixes and time) Largely qualitative Better tools to cost funding need and gap more precisely Selection of interventions not determined by Poor data quality No clear pathway of knowledge of likely impact action based on Weak capacity recommendations Performance framework underpinned by weak data for data analysis systems and impact evaluations Does not cover Adhoc use of adequately the Action plan not always subnational and often is top data relevant health down and malariacentric system areas Better measurement of progress, including improved MPRs It is not about perfection, but improving things! Poor tracking of programmatic activities Mostly top down and nor based on subnational reviews Approaches to estimating funding need and gap is inconsistent and imprecise

24 Strategic use of information purpose and process 1 Reviewing current status situation analysis national, province and district (or equivalent) 4 2 Measuring progress and impact of revised strategic approach through routine, national, district routine surveillance and surveys 3 Operationalizing through subnational (district) operational plans, village level action Planning more efficient and targeted future (subnational (district) level stratification and mix of intervention)

25 NMCP leadership, a collective partnership resource Environment Technical Implementation Funding MoH HMIS Advocacy MoH/NMCP MoH HSD Research MoH Policy Meteorology Other sectors Community

26 Process Country and partnership dialogue Desk review Analysis partnership Data assembly & analysis Stratification & intervention mixes NSP revision, costing & reprioritization National and subnational data and M&E platforms

27 Activities Partnership and NMCP dialogues advanced 5 Phase 1 countries identified (Nigeria, DRC, Mozambique, Tanzania, Uganda) Desk review started Analysis framework document and tools in development Subnational operational planning guidance Subnational of new geospatial data assemblies

28 Theory of change Finances and political capital HRH and commodities Delivery of optimal mix of interventions Reduced malaria mortality Socioeconomic development Political Commitment Health governance and financing Market shaping Strategic use of local information Global learning and guidance

29 Prioritizing and combining interventions to control malaria

30 Prioritizing & combining interventions Many resource allocation decisions are taken without WHO guidance Countries have to decide who gets which interventions, where & when Should Intervention A be de-prioritized in a low burden area to free up resources for Intervention B in a higher burden area? Evidence-based processes inform WHO recommendations Limited information on the effects of combining multiple interventions Little evidence on the impact of withdrawing interventions Impossible to guide every decision with solid data Decisions become more complex as control reveals heterogeneity How to generate better guidance in the absence of robust data?

31 Building better advice (1) 1. Systematic prospective data collection Deliberate, prospective tracking of changes in malaria burden, related to the interventions and strategies deployed in different epidemiological / health system contexts Over time, discern patterns of change in malaria burden when intervention strategies are changed in specific contexts Requires systematic gathering and curation of relevant data Closely linked to the analytical framework Requires investment in data management and analytic capacities

32 Building better advice (2) 2. Derivative guidance Extract from existing guidance context-specific recommendations to build a menu of control options for specific contexts

33 Building better advice (3) 3. Develop a WHO guide to in-country decision making Advise on generic principles for prioritization and mixes of interventions & strategies Encourage decision-making based on in-depth analyses Consider approaches to the prioritization of interventions & strategies (e.g. Health Technology Assessment) Use data and modelling to inform discussion & strengthen the rationale for generic guidance Consider the development of tools to support country-level decision making Consider specific issues encountered when applying the analytical framework at country level

34 Who is involved? Eckl s triangle Interrelated questions that help to identify specific interpretations of the malaria problem What is the problem? And why? Who should solve it? And why? Who owns the problem? Who has the necessary resources? What is the solution? And why? What is no solution? Source: Eckl 2017

35 Equity Malaria is a good litmus test of whether the world is really committed to social justice (Annan)

36 Global Programme of Work Mission Strategic Priorities (and goals) Promote health keep the world safe serve the vulnerable Ensuring health lives and promoting well-being for all ages Strategic shifts Leadership: global Stepping data up to initiate leadership global response Country Drive health impact: impact Locally in every suited response country based on context Focus global Best global public goods guidance on impact Organizational shifts / Measure impact / reshape operating model Focus on impact / One WHO approach / Working in partnership / transform partnerships / strengthen critical system / Foster culture change

37 Summary: What s new?

38 What is different or will be done better? The increase in cases and an urgent need to respond! A comprehensive and integrated technical, political and systems approach (incorporating PHC and UHC) A country led approach by high burden countries Meaningful alignment behind a common approach Increase domestic resources, complemented by an increase in international funding Efficient and effective approach to impact on malaria mortality The value of local evidence to: Make informed choices on the efficient use of resources Establish confidence for further investment Identify where to introduce new technologies and approaches Identify more effective means of using existing tools